“We’re going to be submitting, as soon as our secretary’s approved, almost simultaneously, shortly thereafter, a plan. It’ll be repeal and replace.”
—Donald Trump, January 12, 2017
“It’s kind of like, you know, getting a 30,000-piece jigsaw puzzle for Christmas, and, you know, cleaning off the dining room table and seeing how long it takes to put all the 30,000 pieces together in the right place. It’s not going to be easy.”
—Congressman Jim Sensenbrenner, February 13, 2017
The worst part about campaigning against Obamacare, Republicans are discovering, is that people expect you to come up with a better plan. No such plan exists. If the President and Congress are looking around for someone else to blame for their predicament, they can start with President Dwight Eisenhower.
Ike was the perfect 1950s president. He radiated command and competence, but he wasn’t about to do anything crazy. In the coinciding dawns of the Cold War and the nuclear age, the United States didn’t get blown to smithereens or wipe any civilizations off the face of the earth, so that’s success right there. But he passed up opportunities to lead the country to greatness by courageously opposing McCarthyism or supporting school desegregation in the South, opting instead to let events take their disgusting course.
On health care, he was no ogre, not one of the men his predecessor, President Truman, accused of having “a calculating machine where his heart ought to be.” He spoke emotionally about his mother-in-law’s devastating illness and what it did to his wife’s family. But it was during the Eisenhower Administration—and due to Eisenhower’s decision-making—that our health system learned its neat trick of costing twice as much to give care that’s half as good.
The problem with Eisenhower’s legacy, besides the fact that millions of Americans are broke or sick or both, is that it set the terms of a uniquely complex, hemmed-in debate about what to do next. For the most part, health care in the United States is covered by employer-based private health insurance, so most people—people whose work pays—aren’t interested in reform. Old people have Medicare, which is federally funded and federally run, and they don’t want anybody taking their Medicare away. State-run but partially federally funded Medicaid foots the bills for the poor, whose health is reasonably taken care of compared to their other needs.
'I repeat. What I am recommending is not socialized medicine. Socialized medicine means that all doctors work as employees of the government. The American people want no such system. No such system is here proposed.' Harry Truman
Because this mishmash takes good enough care of enough people, it’s an item of faith in Washington that its pieces must remain inviolate. To start over would piss off 250 million people. Any solution to the problem must work around the broken system that’s already in place, which means the solution must necessarily be broken, too. It’s as if somebody took you to the compost bin and told you to make lunch. You know it’s not going to taste good, but you keep arranging the rotting scraps in novel ways, hoping for the best, and, in the end, eating shit.
When Eisenhower took office in 1952, the modern health care system wasn’t yet set in stone. Most people didn’t have health insurance of any kind, and how to remedy that problem was a hot topic of conversation. Two solutions rose to the top; Eisenhower abhorred one and adored the other.
Abhorred: Harry Truman had campaigned in 1948 on national health care—guaranteed insurance for everyone—which had also been on FDR’s New Deal agenda (though, truth be told, pretty far down on it). The idea had avid supporters in Congress, who introduced a bill to add health insurance to Social Security during every session for 14 years in a row, starting in 1943. But Eisenhower promised to “use every single attribute and influence of the Presidential office to defeat any move toward socialized medicine.”
'One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It's very easy to disguise a medical program as a humanitarian project, most people are a little reluctant to oppose anything that suggests medical care for people who possibly can't afford it.' Ronald Reagan
Adored: Meanwhile, more and more Americans were relying on private health insurance. For years, insurance companies avoided selling health insurance like the plague (against which they wouldn’t insure anyone) because they couldn’t make any money on it. Then in the 1930s, when employers started offering health insurance as a fringe benefit, the calculus changed. Most importantly, since people who went to work every day were by definition healthy, employer-based plans solved the insurance companies’ biggest problem—the fact that the product would attract the sickest customers who cost the most to cover. (This issue, “adverse selection,” hasn’t gone away. It’s the reason for the despised “individual mandate” in Obamacare, which subsidizes expensive sick people by forcing inexpensive healthy people to buy the product.)
The momentum behind private insurance picked up during World War II. Wage controls prevented companies from giving pay raises, so they had to find other ways to recruit and retain employees; health benefits turned out to be an effective enticement. Then, after the war, unions started bargaining for health plans when they negotiated new contracts. Eisenhower liked where the health care system was going, and in 1954, two years into his administration, he gave it another shove in the private-sector direction when he changed the tax code so that employees wouldn’t have to pay taxes on the health insurance premiums their employers paid. The lost tax revenue was massive, but the Eisenhower Administration didn’t seem bothered by how much the government had to pay as long as the insurance was “private.”
While Eisenhower promoted private insurance, the national health care advocates kept agitating. They wanted to know, What about people who don’t work and therefore couldn’t get insurance? Eisenhower, who “where necessary” supported “Government action” at “appropriate levels,” proposed an exquisitely inadequate solution: $25 million to pay the insurance companies back for any losses they might take by insuring riskier customers. Even back then, $25 million was chump change. One clever Democrat, noting that Eisenhower spent plenty of time being treated at the Walter Reed Army Medical Center, said that the former general didn’t get it because he had “been getting free, socialized care almost all his adult life.” The insurance companies were just as withering about the proposal. They were not interested in opening up their books for a crack at a lousy $25 million.
Eisenhower’s Secretary of Health, Education, and Welfare was the next to try to fill the gaps in the employer-based system. She proposed $62.5 million in aid to states to help provide health care for those left out. Eisenhower cut the figure to $20 million (it didn’t pass anyway) and told her “it would be best to try to establish a moderate program in this field while there is in the Executive Department a clear comprehension of the dangers as well as the anticipated advantages.” Translation: let’s do something that won’t work so we can point to it when the Democrats ask for real money.
Eisenhower’s analysis of where the health care debate was headed was spot on. The Democrats did ask for more money to cover more people. Four years after Ike left office, in 1965, Congress passed Medicaid and Medicare, the single-payer system that people who hate single-payer systems forget to hate. By 1966, most Americans had an insecure stake in our piecemeal health system, the pathetic condition that drastically limits the terms of our current debate.
Eisenhower liked to say “in all things which deal with people, be liberal, be human. In all those which deal with the people’s money, their economy, or their form of government, be conservative.” That’s nice but useless. From the point of view of the government, what things deal with people but not money? Eisenhower’s health system was better than what came before it: virtually nothing. The problem is what came after it, which is an ongoing 50-year jury-rigging that is neither human nor conservative and is so blinkered that everyone who enters prepares to abandon all hope. I’d feel sorry for Trump and the Republicans; they have their work cut out for them. But you reap what you sow.
Stephen Ambrose wrote thousands of pages about Eisenhower, including a two volume biography and a condensed biography in a single volume that’s still 660 pages. If you’re annoyed by Ambrose’s admiration for his subject, you can try Jean Edward Smith’s more scholarly Eisenhower in War and Peace, but that’s 976 pages. The Eisenhower installment of the American Presidents Series is mercifully shorter, but unfortunately it’s not as good as you’d want it to be. For my favorite look at the Eisenhower Years—and, in a few chapters, at Eisenhower himself—read David Halberstam’s The Fifties. I love that book, even though he could have used an editor, too. In none of these books, however, will you find much about health care, considered a minor part of Ike’s presidency. The Heart of Power, by David Blumenthal and James Morone, who by the way gave me a B in college, is a strange but satisfying book. It’s sort of a combination biography of the presidents since FDR/account of each president’s personal health situation/appraisal of their health care policies. As far as I know, there’s no better source about presidents and health policy. For a book on 20th century health policy in general, try Paul Starr’s Remedy and Reaction, which focuses on the recent health care debates but starts with valuable historical context.